HomeMy WebLinkAbout0466 OLD CRAIGVILLE ROAD - Health (2) 466 Old Craigville Beach rd.
Centerville P
A = 247 031
flo'-'ordm NO. 152 1/3 ORA
100/l
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
RECEIVED
AUG 2 8 2003
TOWN OF BARNSTABLE
TITLE 5 HEALTH DEPT.
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 466 Old CraiQyille Beach Road
Centerville, MA 02632
Owner's Name: Steve Graves
Owner's Address:
Date of Inspection: July 22, 2003
Name of Inspector: (Please Print) James M. Ford
Company Name: James M. Ford
Mailing Address: P.O. Box 49 Map:247
OSteFyIlle,MA 02655-0049 Parcel: 031
Telephone Number: (508) 862-9400
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
✓ Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: July 23, 2003
The system inspector shall subm'rcopyof this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving
{ authority.
S Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
,
Page 2 of I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 466 Old Craioville Beach Road
Centerville, AM
Owner: Steve Graves
Date of Inspection: July 22, 2003
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass" section need to be replaced or
repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health, will pass.
Answer yes, no or not determined (Y,N,ND) in the for the following statements. If"not determined", please
explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if (with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 466 Old Craizville Beach Road
Centerville, MA
Owner: Steve Graves
Date of Inspection: July 22, 2003
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the
system is not functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
3
Page 4 of 1 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 466 Old Craigyille Beach Road
Centerville, MA
Owner: Steve Graves
Date of Inspection: July 22, 2003
D. System Failure Criteria applicable to all systems:
You must indicate either"yes"or"no"to each of the following for all inspections:
Yes No
✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
✓ Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow
✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped—
✓ Any portion of the SAS,cesspool or privy is below high ground water elevation.
✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
✓ Any portion of a cesspool or privy is within a Zone 1 of a public well.
✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large System:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area- IWPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered
"yes" in Section D above the large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
4
Page 5 of 1 I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 466 Old Craigville Beach Road
Centerville, MA
Owner: Steve Graves
Date of Inspection: July 22, 2003
Check if the following have been done: You must indicate"yes"or"no"as to each of the following:
Yes No
✓ Pumping information was provided by the owner,occupant,or Board of Health
✓ Were any of the system components pumped out in the previous two weeks?
✓ _ Has the system received normal flows in the previous two week period?
✓ Have large volumes of water been introduced to the system recently or as part of this inspection ?
✓ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
✓ Was the facility or dwelling inspected for signs of sewage back up?
✓ Was the site inspected for signs of break out?
✓ _ Were all system components, excluding the SAS, located on site?
✓ Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid, depth of sludge and depth of scum ?
✓ _ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes No
✓ Existing information. For example, a plan at the Board of Health.
✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [310 CMR 15.302(3)(b)].
5
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Page 6 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 466 Old Crai1;ville Beach Road
Centerville, MA
Owner: Steve Graves
Date of Inspection: July 22, 2003
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Number of current residents: 4
Does residence have a garbage grinder(yes or no): No
Is laundry on a separate sewage system (yes or no): No (if yes separate inspection required]
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings, if available(last 2 years usage(gpd)): Unavailable
Sump Pump(yes or no): No
Last date of occupancy: Currently occupied
COMMERCIAIANDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): pd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no)
Non-sanitary waste discharged to the Title 5 system (yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: Unavailable
Was system pumped as part of the inspection (yes or no): No
If yes, volume pumped: gallons-- How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
✓ Septic tank, distribution box, soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes,attach previous inspection records, if any)
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight Tank Attach a copy of the DEP approval
Other(describe):
Approximate age of all components, date installed(if known)and source of information:
Oct. 1197-per as built card
Were sewage odors detected when arriving at the site(yes or no): No
6
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Page 7 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 466 Old Craigville Beach Road
Centerville, MA
Owner: Steve Graves
Date of Inspection: July 22, 2003
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: _cast iron _40 PVC _other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints, venting, evidence of leakage, etc.):
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: To,grade
Material of construction: ✓ concrete _metal _fiberglass _polyethylene
_other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1500 gal.
Sludge depth: 1"
Distance from top of sludge to bottom of outlet tee or baffle: 31"
Scum thickness: /"
Distance from top of cum to top of outlet tee or baffle: 7"
Distance from bottom of scum to bottom of outlet tee or baffle: 15"
How were dimensions determined: Measuring stick
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
Tees were present. The liquid level was even with the outlet invert. There were no signs of leakage.
GREASE TRAP: None (locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _fiberglass _polyethylene _other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage,etc.):
7
Page 8 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 466 Old Craigville Beach Road
Centerville, MA
Owner: Steve Graves
Date of Inspection: July 22, 2003
TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches, etc.):
DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: Even
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of
leakage into or out of box, etc.):
The D-box was level. No solids were present. There were no signs of backup or failure from the leach field.
PUMP CHAMBER: None (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no)
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
8
Page 9 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 466 Old Craigville Beach Road
Centerville, MA
Owner: Steve Graves
Date of Inspection: July 22, 2003
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:
✓ leaching chambers,number: 4-High capacity infiltrators(25'x 11'x 2)per as built card
leaching galleries,number:
leaching trenches,number, length:
leaching fields, number, dimensions:
overflow cesspool,number:
Innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil, condition of vegetation,
etc.):
There were no signs of failure from the leach field. The bottom to grade was approximately 5.
CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth -top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
PRIVY: None (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
9
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Page 10 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 466 Old Craikville Beach Road
Centerville, MA
Owner: Steve Graves
Date of Inspection: July 22, 2003
Map: 247
Parcel: 031
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
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10
' Page 1 I of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 466 Old Craigville Beach Road
Centerville, MA
Owner: Steve Graves
Date of Inspection: July 22, 2003
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 20 +/- feet
Please indicate (check) all methods used to determine the high ground water elevation:
Obtained from system design plans on record- If checked, date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
✓ Checked with local Board of Health-explain: topographic and water contours maps
Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Using the Barnstable topographic map and the Cape Cod Commission water contours map,the maps were showing approximately
20'+/-to ground water at this site.
This report has been prepared and the system inspected and passed as of the date of inspection. This report is
not a warranty or guarantee that the system will function properly in the future. There have been no warranties
or guarantees, either expressed, written or implied, relating to the system, the Inspection and/or this report.
II
No. '' Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
01ppricatton for Mt! ppaal *potent Construction Vermtt
Application for a Permit to Construct( )Repair(i/rUpgrade( )Abandon( ) Ncomplete System ❑Individual Com onents
Location Address or Lot No. �G O 1QG9_ Ut r21Owner's Name,Address
saand
"Tel.No.
Assessor's Map/Parcel
1_09 ®31
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms -3 Lot Size sq. ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow .S3 U gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title Y'
Size of Septic Tank �Op Type of S.A.S. Ca,4c/✓'�— s���S
Description of Soil
Nature of Re airs or Alterations(Answer when applicable) `-ST��i
D� ,r�Gtir'��S� CcvaGi�c i,c�..r.�L-Tve�TGi'j ri✓/ �1 a Si C�f'�.Ge�S i®�S
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Cooeand not to place the system in operation until a Certifi-
cate of Compliance has b ea ,r
Signed 4 Date
Application Approved Date
Application Disapproved for the following reasons
41
Permit No. Date Issued -"
:No. i �`` Fee _2 a
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: r
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
01pprication for Migaar *pztem Conztrurtion Permit
Application for a Permit to Construct( )Repair(l/rpgrade( )Abandon( ) Complete System ❑Individual Com nents
Location Address or Lot No. O(C)CQ U1 Owner's Name,Address and Tel.No.
r w Assessor's Map/Parcel 9 �J« 5���e✓ —
Installer's Name,Address,and Tel.No. J Designer's Name,Address and Tel.No.
`� -�
Type of Building:
Dwelling No.of Bedrooms_3 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 7 3 U gallons per day. Calculated daily flow -3 41 gallons.
Plan Date Number of sheets Revision Date
Title 2V'
Size of Septic Tank r"I /?Type of S.A.S. Cam,46//-,JzJF
�T'S►�z� �s
Description of Soil S[
.Nature of Re airs or Alterations(Answer when applicable) _/`-STa��
�-�o� �r fl��� C�✓Jci/c 1u���G•r�-�ror�s w� 4/�.STIr�.O�5i0��
Date last inspected:
f
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Co and not to place the system in operation until a Certifi-
cate of Compliance has b o ea -7
Signed Date
Application Approved
j Application Disapproved fop,the following reasons
f'
Permit No. Date Issued
4
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSpTS
Certificate of Comptiarlce
THIS IS TO,CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( Upgraded ( )
Abandoned( )by `( N
at y L `6 C 0.��'v i 'R b• h.s has been constructed in accordance
.
with the provisions of Title 5 and the for isposal System on ction Permit No dated
Installer o�et*�CS' Designer
The issuance of this permit sh ll dot be onstrued as a guarantee that the system will function as desig d. Ja D
Date I Inspector
———————————————————————————————————————
No. / Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS -
MiOpoe;ar *p5tem Con.5truction Permit
Permission is hereby granted to Construct( )Repair XPgrade( )Ab ndon
System located at i-I G Cy cy-\ J i� �. �, tV G
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of th' rmit.
Date:�� Approve b i
NOTICE: This Form iS- to I)e wed for (lie Ilepair of Failed • • '�'''
Septic Systems Only
CEIt'I'IFICA11ON OF�SKETCII ANU APPLICATION FOR A DISPOSAL
1VUIt1�S (,UN51 ItUt !UN I'FI091 l' OV1'I'II0U'1' UESI(:NEU PLAN
6'
t
t _
h � AS , hereby certify that the application for disposal works
y '\D — \ `9-7 �concerning the
construction permit signed b me dated
located at �Ca O k o ceA1 � V`l� rrte�s a of the
.. property ,
following criteria:
There are no wetlands within 300 feet of the Proposed Septic system
There are no private wells within 1 So feet of the proposed septic system
The observed groundwater Inble is 14 reel or greater below the bottom of the leaching faellitY
Thcrc is no Increase in now and/or change In use proposed
There are no variances requested or needed.
i
SIGNED
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
IAltach a sketch plan or the proposed system. Also it the licensed installer posesses it certilled Plot plan•
this plan should be submittcdl.
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TOWN OF BARNSTABLE
LOCATION O SEWAGE # -
VELLAGE V/ SSESSOR'S MAP & LO
INSTALLER'S NAME&PHONE go.
SEPTIC TANK CAPACITY �S111U _C W j►1�
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS
BUELDER OR OWNER
PERMITDATE: D COMPLIANCE DATE: '
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility .Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet.
Furnished by
o rrL� n
0
1 Q
(Q 3
,� 3
f TOWN OF BARNSTABLE
L'0CA'l tON ` OL-C Cr4i f V1 &ALII SEWAGE #
VILLAGE Celt rVI ASSESSOR'S MAP & LOT
IN—TALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY Usk! , ^ •
LEACHING FACIL=: (type) (size)
NO. OF BEDROOMS
BUILDER OR OWNER WL GrAVe.s
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leachin facility).. 0 1 Feet
Furnished by��tOL d� J• �Oi' G
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3 ► 33 �.b
771
y 3y 39
9
TOWN OF�BARNSTTABLE f�
LOCATION �� Ol�������`�? Y 2; SEWAGE # -
VYLLAGE nt F° - e�N ASSESSOR'S MAP & LO
INSTALLER'S NAME&PHONE 0.
SEPTIC TANK CAPACITY 1'S1J`17 _�IP ji1�
LEACHING FACILITY: (type) (size)
+ ;
NO.OF BEDROOMS
BUILDER OR OWNER `
RMTTDATE: D CO
PE MPLIANCE DATE: 1
_ '
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
A 2,2 --
�A3
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENT
RECEIVED
MAY 292001
TOWN OF BARNSTABLE
HEALTH DEPT.
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 466 Old Craiqville Rd.
W Hyannisport, MA
Owner's Name: DprnarPst Quinn Tsenstadt
Owner's Address: P Q Box 7 9 A
17
Date of Inspection: 2 —I•, —!3/
Name of Inspector: (please print) W i 1 1 i am E_ . Robinson Sr.
Company Name: William E. Robinson Septic Service
Mailing Address: P O Box -1 0 8 9
Centerville, MA
Telephone Number: (5 0 8) 7 7 5—8 7 7 6
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
G1 Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: 01 Date: 3 a—o
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Healt -or
DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approxing
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page I
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Page 2 of l l
a
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
"+ UBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 466 Old Craigvil l _ Rc3 _
W Hy annisport
Owner: Isenstar3t__
Date of Inspection: .3—Xj_ a /
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. Sys Passes:
I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repa' ed.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Ans r yes,no or not determined(Y,N,ND)in the for the following statements.If"not_determined"please
expla .
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unso d,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the
exis mg tank is replaced with a complying septic tank as approved by the Board of Health.
*A etal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
in icating that the tank is less than 20 years old is available.
D explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
o structed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with
a proval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
explain:
Ile system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obskuc&n is removed
ND explain:
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.Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 466 Old' Craigville Rd.
W HYannisport
Owner: I senstadt
Date of Inspection: 1—;-o—0 /
C Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is fai ing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
_ Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
ystem is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
_ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
_ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more frottl a
private water supply well".Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered.A copy of the analysis must be attached to this form.
3 Other:
3
Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM_ INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 466 Old Craictville Rd.
W Hyannisport
Owner: Isenstadt
Date of Inspection:'3—,7,®—o-/
System Failure Criteria applicable to all systems:.
Yo must indicate"yes"or"no"to each of the following for all inspections:
Yes No
_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
Liquid depth in cesspool is less than 6"below invert or available volume is less than''/z day flow
_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
Any portion of the SAS,cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
Any portion of a cesspool or privy is within a Zone 1 of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
T be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
d.
Y u must indicate either"yes"or"no"to each of the following:
( e following criteria apply to large systems in addition to the criteria above)
yes no
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
_ _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a public water supply well .
If ou have answered"yes"to any question in Section E the system is considered a significant threat,or answered
" es"in Section D above the large system has failed.The owner or operator of any large system considered a
s nificant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15. 04.The system owner should contact the appropriate regional office of the Department.
4
• Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 466 Old Crain-,z; l le Rd.
W Hyannipnri-
Owner: IGenGtadt
Date of Inspection: 3 —X 0
Check if the following have been done You must indicate"yes"or"no"as to each of the following:
Yes Flo
Pumping information was provided by the owner,occupant,or Board of Health
V<Vere any of the system components pumped out in the previous two weeks?
Has the system received normal flows in the previous two week period?
�ave large volumes of water been introduced to the system recently or as part of this inspection?
Were as built plans of the system obtained and examined?(If they were not available note as N/A)
t/ Was the facility or dwelling inspected for signs of sewage back up?
Was the site inspected for signs of break out?
Were all system components,excluding the SAS,located on site
Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes ,no
�/ Existing information.For example,a plan at the Board of Health.
(/ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)[310 CMR 15.302(3)(b)]
5
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Page 6 of 11 '
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:466 Old Cra i gv i 1 1 e Rd.
W HYannisport
Owner: TsensfAdf
Date of Inspection: Q-G
FLOW CONDITIONS
RESIDENTIAL _-
Number of bedrooms(design):M[la'NL-
umber of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 33 6
Number of current residents: 0
Does residence have a garbage grinder(yes or no):�v
Is laundry on a separate sewage system(yes or no): & [if yes separate inspection required]
Laundry system inspected(yes or no):Lu
Seasonal use: (yes or no):
Water meter readings,if a ailable(last 2 years usage(gpd)): 2000 33, 000 gal.
Sump pump(yes or no): It,v 1999 8, 0 0 0 gal.
Last date of occupancy:
CO ERCIAL/INDUSTRIAL
Type o establishment:
Design ow(based on 310 CMR 15.203): gpd
Basis o design flow(seats/persons/sgft,etc.):
Grease p present(yes or no):_
Industr al waste holding tank present(yes or no):
Non-s itary waste discharged to the Title 5 system(yes or no):_
Water eter readings,if available:
Last ate of occupancy/use:
OT ER(describe):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part of the inspection(yes or no):/i
If yes,volume pumped:_gallons--How was quantity pumped determined?
Reason for pumping:
TYP /FF SYSTEM
2e tic distribution box soil absorption system
_ p �, rP Y
_Single cesspool
_Overflow cesspool
—Privy
_Shared system(yes or no)(if yes,attach previous inspection records, if any)
_Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
_Tight tank _Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed if own) nd source of information:
Were sewage odors detected when arriving at the site(yes or no):A_0
6
Page 7 of l l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 466 Old Craig i lle Rd.
W Hyannisport
Owner: Isenstadt
Date of Inspection: �r —;-o—c
BU ING SEWER(locate on site plan)
Depth elow grade:
Materi s of construction:_cast iron _40 PVC_other(explain):
Distan a from private water supply well or suction line:
Co nts(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK:aocate on site plan)
Depth below grade:�_
Material of construction:_concrete_metal_fiberglass_polyethylene
_other(explain)
If tank is metal list age:— Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions: /., -y G
Sludge depth: I—:�..•`
Distance from top of sludge to bottom of outlet tee or baffle: L/ '7
Scum thickness: D
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
How were dimensions determined:_(5_6,-, h— N 16
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of.leakage,etc.):
/6
6ro o,.2�1 _z 7lJ+'! T)
GR)en
E TRAP:_(locate on site plan)
Delow grade:_
Maof construction:_concrete_metal_fiberglass_polyethylene_other
(ex
Dions:
Scckness:
Di from top of scum to top of outlet tee or baffle:
Di from bottom of scum to bottom of outlet tee or baffle:
Daast pumping:
Cots(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as d to outlet invert,evidence of leakage,etc.):
7
Page 8 of l l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 466 Old Craiaville Rd.
W Hyannis port
Owner: Isenstac�t _.
Date of Inspection: 3 —,;Z U`O ,
TI HT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Dep below grade:
Mat rial of construction: concrete metal fiberglass_polyethylene other(explain):
Dim nsions:
Cap city: gallons
Des gn Flow: gallons/day
Al present(yes or no):
Al level: Alarm in working order(yes or no):
D to of last pumping:
C mments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: Z (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
PUMP HAMBER: (locate on site plan)
Pumps i working order(yes or no):
Alarms ' working order(yes or no):
Comm is(note condition of pump chamber,condition of pumps and appurtenances,etc.):
8
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 466 Old Craicrville Rd.
W Hyannisport
Owner: Isenstadt
Date of Inspection: '3 d 1 /
SOIL ABSORPTION SYSTEM(SAS): �/ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
aching pits,number:_
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure, level of ponding, damp soil,condition of vegetation,
etc.): ,
CES POOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Num er and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dime lions of cesspool:
Mate als of construction:
Indic 'ion of groundwater inflow(yes or no):
Co ents(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PR (locate on site plan)
Mate ials of construction:
Dim nsions:
Dep of solids:
Co ents(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
11?
9
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 466 Old Craigvi Ile Rd.
W Hyannis or
Owner: Isenst-adt "
Date of Inspection: 3 a- a'
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building.
J
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/ 7
10
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Page 11 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 466 Old Craiaville Rd.
W Hyannisport
Owner. Isenstadt
Date of Inspection: 3—a-e)— c) 7
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
X
Estimated depth to ground water feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
,Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must des cr be how you established the high ground water elevation:
it